Allocation of patients with liver cirrhosis and organ failure to intensive care:Systematic review and a proposal for clinical practice

AIM: To propose an allocation system of patients with liver cirrhosis to intensive care unit (ICU), and developed a decision tool for clinical practice. METHODS: A systematic review of the literature was performed in PubMed, MEDLINE and EMBASE databases. The search includes studies on hospitalized patients with cirrhosis and organ failure, or acute on chronic liver failure and/or intensive care therapy. RESULTS: The initial search identified 660 potentially relevant articles. Ultimately, five articles were selected; two cohort studies and three reviews were found eligible. The literature on this topic is scarce and no studies specifically address allocation of patients with liver cirrhosis to ICU. Throughout the literature, there is consensus that selection criteria for ICU admission should be developed and validated for this group of patients and multidisciplinary approach is mandatory. Based on current available data we developed an algorithm, to determine if a patient is candidate to intensive care if needed, based on three scoring systems: premorbid Child-Pugh Score, Model of End stage Liver Disease score and the liver specific Sequential Organ Failure Assessment score. CONCLUSION: There are no established systems for allocation of patients with liver cirrhosis to the ICU and no evidence-based recommendations can be made

Swelling of PDMS Networks in Solvent Vapours; Applications for Passive RFID Wireless Sensors

The relative degree of swelling of a poly(dimethylsiloxane) (PDMS) network in organic vapours is demonstrated to be related to the chemical and physical properties of the organic compounds. The swelling ratio, based on volume change, QV, is directly correlated with the Hansen solubility parameters, dd, dp and dh and the vapour pressures of the organic vapours employed. A practical use for such PDMS networks in combination with an understanding of the relationship is demonstrated by the use of PDMS as a mechanical actuator in a prototype wireless RFID passive sensor. The swelling of the PDMS displaces a feed loop resulting in an increase in transmitted power, at a fixed distance

How do bacteraemic patients present to the emergency department and what is the diagnostic validity of the clinical parameters; temperature, C-reactive protein and systemic inflammatory response syndrome?

OBJECTIVE: Although blood cultures are often ordered based on the presence of fever, it is a clinical challenge to identify patients eligible for blood cultures. Our aim was to evaluate the diagnostic value of temperature, C-reactive-protein (CRP), and Systemic Inflammatory Response Syndrome (SIRS) to identify bacteraemic patients in the Medical Emergency Department (MED). METHODS: A population-based cohort study including all adult patients at the MED at Odense University Hospital between August 1st 2009 - August 31st 2011. RESULTS: 11,988 patients were admitted to the MED within the study period. Blood cultures were performed on 5,499 (45.9%) patients within 2 days of arrival, of which 418 (7.6%) patients were diagnosed with bacteraemia. This corresponded to 3.5% of all patients. 34.1% of the bacteraemic patients had a normal rectal temperature (36.0°–38.0°C) recorded at arrival, 32.6% had a CRP < 100 mg/L and 28.0% did not fulfil the SIRS criteria. For a temperature cut-point of >38.0°C sensitivity was 0.64 (95% CI 0.59–0.69) and specificity was 0.81 (0.80–0.82) to identify bacteraemic patients. CONCLUSION: One third of the acute medical bacteraemic patients had a normal temperature at arrival to the MED. A normal temperature combined with a CRP < 100 mg/L and no SIRS criteria, ruled out bacteraemia

Early detection of fatty liver disease in primary care

Introduktion: Fedtleversygdom er en stigende global sygdomsbyrde, der spænder fra simpelfedtophobning til alvorlig skrumpelever med høj dødelighed. Fedtleversygdom kan være forårsagetaf alkoholoverforbrug (Alkoholrelateret leversygdom, ArLD) eller af fedme, metabolisk syndrom ogtype-2-diabetes (non-alkoholisk fedtleversygdom, NAFLD), eller af en kombination deraf. Diagnostikaf fedtleversygdom udføres med høj nøjagtighed ved brug af leverbiopsi og senest også ved brug afnon-invasive tests, så som transient elastografi (TE), dog er disse værktøjer primært begrænset tilspecialiserede hospitalsafdelinger. Men grundet den stigende forekomst af patienter der er i risikofor at udvikle fibrose i leveren, står sundhedsvæsenet i de kommende år over for en stigendeudfordring fra henvisninger af patienter i risiko. For at løse denne udfordring, har vi brug for simplediagnostiske tests tilgængelige i primær praksis, til at promovere tidlig opsporing af leversygdom, ogoptimere henvisningsmønstrene.Formål: I det første studie undersøgte vi henvisningsmønstrene for patienter med mistanke om leversygdom fra primær- til sekundærsektoren. I det andet studie undersøgte vi standard leverfunktionstests evne til at finde patienter med fremskredet arvæv i leveren i primærsektoren. Desuden testede vi hvordan læger præsterer, når de bliver bedt om at vurdere risikoen for fibrose og cirrose i virkelige patientcases. I det tredje studie udviklede og testede vi en statistisk model som en potentiel løsning på den diagnostiske udfordring af leversygdom i primær praksis. I det fjerde og sidste studie udviklede vi en ny model baseret på kunstig intelligens, der er i stand til at forudsige arvæv i leveren i lav-risiko befolkningsgrupper ved hjælp af rutinemæssige tilgængelige patientdata.  Metode: I det første studie læste vi samtlige henvisninger i en toårig periode til Gastroenterologisk og Hepatologisk Afdeling på Odense Universitetshospital. Derefter fulgte vi op på alle patienter med mistanke om leversygdom, ved at gennemgå journalen systematisk, med det formål at kortlægge konsekvensen af henvisningen for den enkelte patient. Vurderingen af lægernes præstation blev udført som et tilfældigt udvalg af hepatologer og praktiserende læger. Det andet studie er baseret på et leverbiopteret-prospektivt kohortestudie af 225 patienter med et tidligere eller nuværende alkoholoverforbrug. I det tredje studie udviklede og testede vi en diagnostisk algoritme, kaldet LiverPRO, som er et klinisk beslutningsstøtte værktøj til brug i primær praksis. I det sidste og fjerde studie havde vi det samme formål som i LiverPRO studiet, men ønskede at avancere metoden og undersøge potentialet af machine learning modeller. Vi udviklede seks ensemblemodeller (kaldet LiverAID) med forskellige kompleksiteter, ved hjælp af en prospektiv screeningkohorte på 3352 asymptomatiske deltagere. Resultater: Vi fandt at mere end halvdelen (54%) af de personer, der henvises til specialistudredning på mistanke om leversygdom er ”lever-raske”, hvorfor deres henvisning potentielt kunne have været undgået, og sundhedsressourcer kunne være sparet. Lever rask var defineret som ingen tilstedeværelse af alvorlig lever sygdom, så som lever inflammation, fibrose, eller cirrose. Lever steatose blev betragtes som værende lever rask i dette studie. Undersøgelsen viste også at 17% af patienterne blev henvist på et alvorligt sygdomsstadie, med dekompenseret levercirrose. Vi har vist at standardblodprøver er dårlige til at påvise arvæv i leveren, og at lægernes evner er begrænsede og med stor forskellighed i kappaværdier. I modsætning hertil, fandt vi at LiverPRO-scoren kan diagnosticere fibrose i leveren med en diagnostisk præcision på 0.85 og 0.80 i en kohorte med henholdsvis høj prævalens og lav prævalens. Kombineret med en meget lav pris på de rutinemæssige leverblodprøver og en let fortolkelig score fra 0-100 %, kan scoren være et nyttigt screeningsværktøj og beslutningshjælp for henvisningsmønstre i primær praksis. Endelig fandt vi at LiverAID-modellerne med høj nøjagtighed (AUC 0.86-0.94) kunne identificere patienter med tegn til arvæv i leveren og havde en markant bedre diskriminerende evne (AUC 0.70-0.76) end standard blodprøvebaserede scores.   Konklusion: Henvisningsmønstrene for patienter med mistanke om fedtleversygdom fra primær praksis er uhensigtsmæssige. De eksisterende værktøjer, som f.eks. levertal, er af begrænset nytte. Algoritmer baseret på ikke-invasive markører er potentielt stærke løsninger imod denne stigende udfordring vores sundhedssystem.Introduction: fatty liver disease is an increasing global burden, ranging from simple steatosis todecompensated liver cirrhosis with high mortality rates. Fatty liver disease can be caused by excessivealcohol use (alcohol-related liver disease, ArLD) or by obesity, metabolic syndrome, type-2 diabetes(non-alcoholic fatty liver disease, NAFLD), or a combination of some of the aforementioned. Diagnosisof fatty liver disease can be performed with accurate precision using liver biopsies and, more recently,non-invasive tools such as transient elastography (TE). However, these tools are typically limited tospecialized in-hospital departments. Due to the high, and increasing, prevalence of patients at risk ofdeveloping liver fibrosis, the healthcare system is faced with an increasing burden from referrals ofat risk patients. To solve this, simple diagnostic tools available in primary care are highly needed forpromoting timely disease detection and optimizing referral pathways. Aims: In the first paper,we investigated the referral patterns of patients with suspicion of liver disease from primary care to secondary care. In the second paper, we evaluated standard liver function tests used to diagnose advanced liver fibrosis in primary care. Furthermore, we evaluated how doctors perform when assessing the risk of fibrosis and cirrhosis in real-life cases. In the third paper, we developed and validated a statistical model to meet the diagnostic challenge of liver disease in primary care. In the fourth paper we developed a novel model based on artificial intelligence (AI), that enabled us to predict significant liver fibrosis in low-prevalence populations using routinely collected patient data.Methods: In the first paper, we read all referral letters during a two-year period (2016+2017) that were submitted to the department of Gastroenterology and hepatology at Odense University Hospital. We then followed up by looking at patient records of all patients that were referred with a suspicion of liver disease in order to map the outcome of the referral for each individual patient. The assessment of the doctor’s performance was performed on a random sample of hepatologists and primary care physicians. The second paper is based on a liver-biopsied prospective cohort study of 225 patients with prior or ongoing alcohol overuse. In the third paper, we developed and validated a diagnostic algorithm called LiverPRO to detect liver fibrosis in primary care. In the fourth paper, we had the same purpose in mind as in the LiverPRO paper but wanted to advance the methodologies to explore the potential of machine-learning models. We built six ensemble-learning models (called LiverAID) with different complexities using a prospective screening cohort of 3,352 asymptomatic subjects. Results: We found that more than half (54%) of the individuals that are referred for specialist evaluation on suspicion of liver disease are liver healthy, and referrals could potentially have been avoided saving healthcare resources. Liver healthy was defined as no presence of severe liver diseases, such as liver inflammation, fibrosis, or cirrhosis. Liver steatosis was considered liver healthy in this study. We found that 17% of the patients were referred too late, with decompensated liver cirrhosis. Furthermore, we have shown that standard blood samples are inadequate to detect liver fibrosis and that the doctors’ abilities are limited with substantial divergence in kappa values In contrast, we found that the LiverPRO score could diagnose fibrosis with a diagnostic accuracy of 0.85 and 0.80, in both a high-prevalence and a low-prevalence cohort, respectively. Combined with a very low cost and an easily interpretable score from 0-100%, the score could be a useful screening tool and decision aid for primary care referral pathways. Finally, we found that the LiverAID models appropriately identified patients with significant liver fibrosis (TE ≥8 kPa), (AUC 0.86-0.94) and had a significantly superior discriminative ability (AUC 0.70-0.76) than standard blood-based indices. Conclusion: The referral patterns of patients with suspicion of fatty liver disease from primary care are inadequate, and existing tools such as liver function tests are of limited guidance. Algorithms based on non-invasive markers are potentially strong solutions to solve this growing challenge in the healthcare system. <br/

Young migrant students’ motivators and drive for obtaining education

This article investigates how students from migrant backgrounds describe their motivators and drive for obtaining an education. It is based on a qualitative study of 17 young people aged 16-24. All are students in combination classes at a large upper-secondary school in Eastern Norway and are recent arrivals in Norway with little prior education. Half aspire to higher education, while the others are applying for vocational training. In this article, we link these educational ambitions to four forms of motivation. The immigrant motivator relates to high academic expectations among parents and other family members. In addition to the immigrant motivator, there is what we refer to as the middle-class motivator, where parents of low socio-economic status exert influence in a way that can be understood as a kind of middle-class behaviour. The world-citizen motivator encompasses the students’ desires to contribute by giving something back to their home countries, the host country, and the global community. The opportunity motivator is linked to the efforts of the school community to provide an inclusive and facilitative environment for this group of students. Schools that offer adapted and differentiated teaching, customized to the needs of individual students, as with combination classes, seem to function as important protective factors

Uptake of and attitudes towards influenza vaccination among Danish hospital healthcare workers

INTRODUCTION Until now, influenza vaccination has not been officially recommended to healthcare workers (HCWs) in Denmark. Even so, many hospitals have been offering vaccination for their HCWs for some years. Nonetheless, uptake has remained low. We conducted a survey to determine predictors for vaccine uptake and to clarify the attitude of Danish HCWs towards employer-sponsored influenza vaccination.METHODS An online questionnaire covering demographics, uptake of and thoughts about the influenza vaccine was distributed by e-mail to hospital staff. Analyses identifying factors associated with vaccine uptake were conducted.RESULTS The response rate was 28% with 3,130 HCWs participating. Overall, 51% had received influenza vaccination. Formerly vaccinated participants were more likely to be vaccinated again. Perception of own gain, patient gain and a workplace recommendation were key incentives for vaccine uptake. The main reported reasons for rejecting vaccination were perceiving immunisation as a private matter, not feeling vulnerable to influenza and fear of vaccine side effects. Women, participants ≤ 49 years and participants with children living at home were less likely to be vaccinated.CONCLUSIONS To improve influenza vaccine uptake among HCWs, campaigns targeting newly employed staff should be conducted thereby establishing the basis for future vaccination behaviour. Efforts should be made to increase vaccine acceptance among women, younger employees and nursing staff.FUNDING none.TRIAL REGISTRATION not relevant

Beyond mixed methods:a pluralist approach to objects in interdisciplinary teaching and learning

The study of objects holds a central place in research on interdisciplinary research practices, yet we know little about the role of objects in facilitating or hindering interdisciplinary learning in higher education. This article develops a pluralist, relational, and dynamic approach to studying the role of objects in interdisciplinary teaching and learning. We document the potential for objects to perform different functions depending on how they are employed and engaged in educational settings. Based on a small, exploratory case study of teaching-learning dynamics at an interdisciplinary MSc course, we examine the roles performed by three very different objects: the dominant object of mixed methods, an interdisciplinary mapping exercise introduced by the teacher, and the spontaneously emerging epistemic object of “perceptions”. We find clear limitations of the dominant mixed-methods approach to interdisciplinarity: while the approach provides a simple and efficient way to organize interdisciplinary collaboration, it risks reinforcing disciplinary boundaries rather than enabling their crossing. Although this gives students the impression of doing interdisciplinary work—and enables them to do so at a relatively superficial level—it simultaneously undercuts the potential for deeper learning. In contrast, we found the “epistemic” object of “perceptions”, that surfaced spontaneously in a student discussion, provided opportunities for transformative understanding across disciplines. We conclude the paper with some reflections on the learning potential of troublesome differences and our role as teachers in balancing improvisation and scaffolding to stimulate deeper interdisciplinary learning beyond mixed methods. In our discussion, we draw upon the concept of threshold concepts to better understand how objects can variously serve as bridges for communication or as portals to more profound interdisciplinary understanding, suggesting new directions for research on objects in teaching and learning contexts.</p

Uptake of and attitudes towards influenza vaccination among Danish hospital healthcare workers

INTRODUCTION Until now, influenza vaccination has not been officially recommended to healthcare workers (HCWs) in Denmark. Even so, many hospitals have been offering vaccination for their HCWs for some years. Nonetheless, uptake has remained low. We conducted a survey to determine predictors for vaccine uptake and to clarify the attitude of Danish HCWs towards employer-sponsored influenza vaccination.METHODS An online questionnaire covering demographics, uptake of and thoughts about the influenza vaccine was distributed by e-mail to hospital staff. Analyses identifying factors associated with vaccine uptake were conducted.RESULTS The response rate was 28% with 3,130 HCWs participating. Overall, 51% had received influenza vaccination. Formerly vaccinated participants were more likely to be vaccinated again. Perception of own gain, patient gain and a workplace recommendation were key incentives for vaccine uptake. The main reported reasons for rejecting vaccination were perceiving immunisation as a private matter, not feeling vulnerable to influenza and fear of vaccine side effects. Women, participants ≤ 49 years and participants with children living at home were less likely to be vaccinated.CONCLUSIONS To improve influenza vaccine uptake among HCWs, campaigns targeting newly employed staff should be conducted thereby establishing the basis for future vaccination behaviour. Efforts should be made to increase vaccine acceptance among women, younger employees and nursing staff.FUNDING none.TRIAL REGISTRATION not relevant

Uptake of and attitudes towards influenza vaccination among Danish hospital healthcare workers

INTRODUCTION Until now, influenza vaccination has not been officially recommended to healthcare workers (HCWs) in Denmark. Even so, many hospitals have been offering vaccination for their HCWs for some years. Nonetheless, uptake has remained low. We conducted a survey to determine predictors for vaccine uptake and to clarify the attitude of Danish HCWs towards employer-sponsored influenza vaccination.METHODS An online questionnaire covering demographics, uptake of and thoughts about the influenza vaccine was distributed by e-mail to hospital staff. Analyses identifying factors associated with vaccine uptake were conducted.RESULTS The response rate was 28% with 3,130 HCWs participating. Overall, 51% had received influenza vaccination. Formerly vaccinated participants were more likely to be vaccinated again. Perception of own gain, patient gain and a workplace recommendation were key incentives for vaccine uptake. The main reported reasons for rejecting vaccination were perceiving immunisation as a private matter, not feeling vulnerable to influenza and fear of vaccine side effects. Women, participants ≤ 49 years and participants with children living at home were less likely to be vaccinated.CONCLUSIONS To improve influenza vaccine uptake among HCWs, campaigns targeting newly employed staff should be conducted thereby establishing the basis for future vaccination behaviour. Efforts should be made to increase vaccine acceptance among women, younger employees and nursing staff.FUNDING none.TRIAL REGISTRATION not relevant